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SAN JOAQUIN COUNTLIC HEALTH SERVICES - ENVIRONMENTAL HEALT�ISION (�,,) oy o 100 <br /> MASTERFILE RECORD INFORMATION FORM EH 01 15 (OWNFAC) Revis 5/14/93 <br /> NEN FACILITY CHANGE OF OWNER DATE OF OWNER CHANGE / /_ INACTIVE <br /> Prior Rorer <br /> UNDER CONSTRUCTION CHANGE OF BILLING DATE OF BILLING CHANGE / /_ DELETE <br /> OWNER FILE <br /> OWNER ID CASE # BILLING PARTY Y / N <br /> t1 l , p <br /> OWNER NAME MV'5TWHUrI0' X 'e)(J IL61-( D ' 5AAIC y TOWE <br /> R HOME PHONE ( ) <br /> 11 r �/ p <br /> OWNER DBA/t /v� n A t� OWNER WRK/BUS PH Q r ) OJ`- �Q D <br /> ADDRESS U�/`OAA T nnP-.cAT b tn; <br /> CITY jL AT 11 4p-o 1-I� Q j - /7ST'A`TE C _ ZIP Alm / � ; 3 ' <br /> MAILING ADDRESS St-1RRpC DEP01� "'1� - " KCATD ,J (���rL� � _ 108 <br /> CARE OF PCl!.��-rc']�iz nKALUS14 (A5 Le Q[� <br /> CITY t-FT 1 4 e-O STATE ZIP r `J *33 ' <br /> BUSINESS CODE NATURE OF OWNER BUSINESS <br /> FACILITY FILE <br /> FACILITY ID <br /> '._,l BILLING PARTY <br /> # �a <br /> � pp� <br /> _ # OF EMPLOYEES <br /> FACILITY NAME �D Q(�—//p / 50,4kk *''Q PO-r / TRUST LANDS? Y / N <br /> FACILITY ADDRESS t J'11/" ") lJ�� J `� I� �_ HOME PH ( ) <br /> CROSS STREET RUSH <br /> PH ( ) <br /> it � V <br /> CITY � �b STATE CIA ZIP <br /> Census ----` �----- BCS Dist Location Code City Code ----------- <br /> MAILING ADDRESS c '✓o APM # <br /> CARE OF SIC CODE <br /> CITY STATE ZIP <br /> GENERAL TYPE of BUSINESS at this FACILITY <br /> UST FAC STATUS CODE BUSINESS CODE BUSINESS TYPE (UST) <br /> THIRD PARTY BILLING ILKy�INFORMATIO-^NF <br /> NAME I� �I N 1i(JTC(?JVt}DOFA(.- _ HOME PHONE <br /> MAILING ADDRESS Ia 38�j 0t,b PLjgCCQy/„LC 900 BUSH PHONE ( �b ) 3k3 - 533 }— <br /> CARE OF IIl1l co �tl4) V DYKE Page I" <br /> AT <br /> CITY � CT/Aki\ ID STATE _ _ Zip � / <br />